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Original Investigation
April 3, 2017

Effect of Reverse Triage on Creation of Surge Capacity in a Pediatric Hospital

Author Affiliations
  • 1Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 2Johns Hopkins Office of Critical Event Preparedness and Response, Johns Hopkins Institutions, Baltimore, Maryland
  • 3Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
JAMA Pediatr. 2017;171(4):e164829. doi:10.1001/jamapediatrics.2016.4829
Key Points

Question  In the event of a disaster or serious hospital crowding, how much surge capacity within a hospital can be realized from various strategies, including safe early discharge (reverse triage) of pediatric inpatients?

Findings  In a year-long retrospective cohort study, 11% of 501 patients in aggregate from 7 hospital services were eligible for immediate low-risk reverse triage, with the psychiatry unit accounting for more than half of this incremental capacity. With multiple strategies that included reverse triage, an estimated 84% surge capacity could be realized within 4 days.

Meaning  Considerable surge capacity may exist in pediatric hospitals, and a low-risk reverse triage strategy realizes only a modest contribution.


Importance  The capacity of pediatric hospitals to provide treatment to large numbers of patients during a large-scale disaster remains a concern. Hospitals are expected to function independently for as long as 96 hours. Reverse triage (early discharge), a strategy that creates surge bed capacity while conserving resources, has been modeled for adults but not pediatric patients.

Objective  To estimate the potential of reverse triage for surge capacity in an academic pediatric hospital.

Design, Setting, and Participants  In this retrospective cohort study, a blocked, randomized sampling scheme was used including inpatients from 7 units during 196 mock disaster days distributed across the 1-year period from December 21, 2012, through December 20, 2013. Patients not requiring any critical interventions for 4 successive days were considered to be suitable for low-risk immediate reverse triage. Data were analyzed from November 1, 2014, through November 21, 2016.

Main Outcomes and Measures  Proportionate contribution of reverse triage to the creation of surge capacity measured as a percentage of beds newly available in each unit and in aggregate.

Results  Of 3996 inpatients, 501 were sampled (268 boys [53.5%] and 233 girls [46.5%]; mean [SD] age, 7.8 [6.6] years), with 10.8% eligible for immediate low-risk reverse triage and 13.2% for discharge by 96 hours. The psychiatry unit had the most patients eligible for immediate reverse triage (72.7%; 95% CI, 59.6%-85.9%), accounting for more than half of the reverse triage effect. The oncology (1.3%; 95% CI, 0.0%-3.9%) and pediatric intensive care (0%) units had the least effect. Gross surge capacity using all strategies (routine patient discharges, full use of staffed and unstaffed licensed beds, and cancellation of elective and transfer admissions) was estimated at 57.7% (95% CI, 38.2%-80.2%) within 24 hours and 84.1% (95% CI, 63.9%-100%) by day 4. Net surge capacity, estimated by adjusting for routine emergency department admissions, was about 50% (range, 49.1%-52.6%) throughout the 96-hour period. By accepting higher-risk patients only (considering only major critical interventions as limiting), reverse triage would increase surge capacity by nearly 50%.

Conclusions and Relevance  Our estimates indicate considerable potential pediatric surge capacity by using combined strategic initiatives. Reverse triage adds a meaningful but modest contribution and may depend on psychiatric space. Large volumes of pediatric patients discharged early to the community during disasters could challenge pediatricians owing to the close follow-up likely to be required.